Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data

Beitrag in einer Fachzeitschrift


Details zur Publikation

Autorinnen und Autoren: Johnston C, Burns R, McNeil J, Tress BM, Campbell BC, Williams M, Ma H, Ringleb PA, Parsons MW, Churilov L, Bendszus M, Hsu C, Kleinig TJ, Fatar M, Leys D, Molina C, Wijeratne T, Curtze S, Barber PA, Bladin CF, Yassi N, Pfaff JA, Sharma G, Bivard A, Schwab S, Schellinger PD, Yan B, Mitchell PJ, Serena J, Toni D, Thijs V, Hacke W, Davis SM, Donnan GA
Zeitschrift: Lancet
Jahr der Veröffentlichung: 2019
Band: 394
Heftnummer: 10193
Seitenbereich: 139-147
ISSN: 0140-6736
eISSN: 1474-547X


Abstract

Background: Stroke thrombolysis with alteplase is currently recommended 0–4·5 h after stroke onset. We aimed to determine whether perfusion imaging can identify patients with salvageable brain tissue with symptoms 4·5 h or more from stroke onset or with symptoms on waking who might benefit from thrombolysis. Methods: In this systematic review and meta-analysis of individual patient data, we searched PubMed for randomised trials published in English between Jan 1, 2006, and March 1, 2019. We also reviewed the reference list of a previous systematic review of thrombolysis and searched ClinicalTrials.gov for interventional studies of ischaemic stroke. Studies of alteplase versus placebo in patients (aged ≥18 years) with ischaemic stroke treated more than 4·5 h after onset, or with wake-up stroke, who were imaged with perfusion-diffusion MRI or CT perfusion were eligible for inclusion. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] score 0–1) at 3 months, adjusted for baseline age and clinical severity. Safety outcomes were death and symptomatic intracerebral haemorrhage. We calculated odds ratios, adjusted for baseline age and National Institutes of Health Stroke Scale score, using mixed-effects logistic regression models. This study is registered with PROSPERO, number CRD42019128036. Findings: We identified three trials that met eligibility criteria: EXTEND, ECASS4-EXTEND, and EPITHET. Of the 414 patients included in the three trials, 213 (51%) were assigned to receive alteplase and 201 (49%) were assigned to receive placebo. Overall, 211 patients in the alteplase group and 199 patients in the placebo group had mRS assessment data at 3 months and thus were included in the analysis of the primary outcome. 76 (36%) of 211 patients in the alteplase group and 58 (29%) of 199 patients in the placebo group had achieved excellent functional outcome at 3 months (adjusted odds ratio [OR] 1·86, 95% CI 1·15–2·99, p=0·011). Symptomatic intracerebral haemorrhage was more common in the alteplase group than the placebo group (ten [5%] of 213 patients vs one [<1%] of 201 patients in the placebo group; adjusted OR 9·7, 95% CI 1·23–76·55, p=0·031). 29 (14%) of 213 patients in the alteplase group and 18 (9%) of 201 patients in the placebo group died (adjusted OR 1·55, 0·81–2·96, p=0·66). Interpretation: Patients with ischaemic stroke 4·5–9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis. Funding: None.


FAU-Autorinnen und Autoren / FAU-Herausgeberinnen und Herausgeber

Schwab, Stefan Prof. Dr.
Lehrstuhl für Neurologie


Einrichtungen weiterer Autorinnen und Autoren

Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille)
China Medical University (CMU) / 中國醫藥大學
Helsinki University Central Hospital (HUCH) / Helsingin seudun yliopistollinen keskussairaala (HYKS)
Royal Adelaide Hospital
Ruprecht-Karls-Universität Heidelberg
The University of Melbourne
Università degli studi "La Sapienza"
Universitat de Barcelona (UB) / University of Barcelona
Universitat de Girona
Universitätsklinikum Knappschaftskrankenhaus Bochum
University of Auckland


Zitierweisen

APA:
Johnston, C., Burns, R., McNeil, J., Tress, B.M., Campbell, B.C., Williams, M.,... Donnan, G.A. (2019). Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet, 394(10193), 139-147. https://dx.doi.org/10.1016/S0140-6736(19)31053-0

MLA:
Johnston, C., et al. "Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data." Lancet 394.10193 (2019): 139-147.

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Zuletzt aktualisiert 2019-23-07 um 09:38